Transit Safety 2022
Transit Safety 2022
Transit Safety 2022
ELISE GARVEY
PETER HEINECCIUS
BEN THOMPSON
Executive Summary
Since 2018, Metro Transit buses have traveled over 200 million miles
and have been involved in 104 preventable incidents with a reported
injury. While Metro Transit’s Safety & Security Division reviews
thousands of incidents each year, we found that Metro Transit could
improve its review by collecting and analyzing data on additional
indicators of risks, including less serious incidents, customer
complaints, and operator traffic tickets. We also found that operators
receive safety training after an incident, but more regular training for
all operators could help prevent collisions, lowering the potential for
injuries and costs.
KING COUNTY AUDITOR’S OFFICE
APRIL 19, 2022
We would like to acknowledge that the already demanding work performed by the Metro Transit
Department became even more challenging during the COVID-19 pandemic. During this audit, Metro
Transit was engaged with building back service and staffing challenges caused by the pandemic. Despite
these challenges, Metro Transit staff were responsive and cooperative.
The nature of performance audits is to focus on areas for improvement—this does not mean the
staff of Metro Transit are not also doing good work in collision and injury prevention under
challenging circumstances. While driving any vehicle inherently presents the possibility of colliding with
other vehicles or objects, causing injury to people or damage to property, buses still are one of the safest
forms of travel. When incidents do happen, Metro Transit has processes in place for reporting and
reviewing incidents and a division dedicated to safety and security that helps Metro Transit determine its
response measures. This report identifies improvements Metro Transit can make to those processes. We
also recognize the work of staff in the Safety & Security and Operations divisions, which developed and
implemented Metro Transit’s current safety management system.
Metro Transit responds to incidents through several measures, including an incident review
process, operator re-training, a drug and alcohol program, bus maintenance, and bus design
improvements. These measures are part of a safety management system and are intended to address
issues that can help prevent collisions and injuries involving coaches, like operator behaviors and skills,
keeping buses in good repair, and ensuring that buses are designed with safety in mind. Metro Transit
leadership also told us that changes in service levels and traffic conditions during the COVID-19
pandemic provided more information about how agency-level policy decisions may affect safety by
competing with operator focus on safe driving. For example, the general manager indicated that the
department is investigating moving away from fixed-time service (e.g., the bus should arrive at exactly
1:32 p.m.) and toward more regular and frequent service (e.g., there will be another bus within the next 10
minutes). By removing fixed schedules, Metro Transit hopes that operators will feel less pressure to speed
up if they are running behind, which will, in turn, reduce the risk of collisions and injuries.
This report contains references to injuries and fatalities that resulted from incidents with Metro
Transit buses.
i
KING COUNTY AUDITOR’S OFFICE
APRIL 19, 2022
REPORT HIGHLIGHTS
Metro Transit Department buses are involved in thousands of While one of the safest forms of
safety incidents each year, but few incidents result in serious travel, Metro Transit buses still have
injuries. Metro Transit has a response system in place that the potential to cause grave injuries
includes measures such as reviewing incidents to assess for any through serious collisions. For
injuries or property damage. For more serious incidents, Metro instance, over the past four years
Transit takes additional measures, like operator post-incident there have been four fatalities and
re-training and discipline. The Safety & Security Division also four debilitating injuries involving
looks for patterns across incidents to find opportunities to buses, even though Metro Transit
prevent future collisions and injuries. found that bus operators would not
have been able to prevent any of
We found that while Metro Transit takes steps to respond to
these particular incidents. In addition
incidents, it could expand these measures to be more proactive
to the human cost, King County also
in its prevention efforts. For example, Metro Transit has fewer
risks reputational damage and has
formal response steps for incidents that did not result in injury
paid over $15 million in claims in the
or damage. Additionally, the Safety & Security Division does
past five years. The County’s insurance
not have efficient access to data, such as traffic tickets and
costs are also rising in 2022, in part
customer complaints, which could help identify risks for future
because of national trends regarding
incidents. Lastly, while staff work to find issues that contributed
collisions and rising jury awards. This
to incidents, they do not capture this information in the
is why the Office of Risk Management
department’s incident data system, making it more difficult to
Services consistently regards collisions
identify emerging patterns.
and injuries to be among the top risks
Metro Transit provides continuing education and post-incident to the County. The total number of
training to operators but does not require regular training on collisions fell during the pandemic,
basic skills and safety expectations—as suggested by the but it is likely to increase again as
Transit Cooperative Research Program—to help prevent skill service and traffic return to pre-
loss. This reactive model of training can also create a pandemic levels.
perception among some operators that training is a form of
This audit looks at the steps Metro
punishment. More regular re-training could reduce this stigma
Transit takes as an agency to reduce
and prevent future collisions and injuries.
the likelihood that collisions or
injuries will occur.
What We Recommend
ii
KING COUNTY AUDITOR’S OFFICE
APRIL 19, 2022
TABLE OF CONTENTS
i Report Highlights
1 Improved Data and Training Could Help Prevent Collisions and Injuries
APPENDICES
8 Executive Response
15 List of Recommendations
Improved Data and Training Could Help Prevent
Collisions and Injuries
Riding a bus Transit is one of the safest forms of travel for passengers, but collisions and
is one of the serious injuries involving a bus remain one of the largest risks to King County.
safest ways Metro Transit has processes for reporting incidents and a division that reviews every
to travel reported incident. Metro Transit requires operators to submit reports whenever there
is a safety incident. While there are thousands of safety incidents reported each year,
a small percentage involve serious injuries. 2 Still, incidents involving buses have the
potential to cause injuries and damage and the Office of Risk Management Services
includes collisions among its most serious risks to the County.
1 Throughout this report, we use the term “incident” to describe any event involving a Metro Transit bus where there is a
possibility for damage or injury. For example, this includes collisions where the bus contacts another vehicle, a
pedestrian, or an object. Incidents also include events that do not involve a collision but could involve an injury such as if
a passenger falls when stepping off the bus. Metro Transit and other government and industry agencies have specific
terms they use for describing different types of events.
2 King County does not know the exact number of serious injuries due to data limitations, such as if someone did not
report an injury to Metro Transit, and because the department only evaluates the severity of an incident that led to an
injury if the incident was preventable.
Metro Transit Metro Transit has a system in place that reviews all incidents but reserves deeper
focuses on analysis for more serious incidents. While the Safety & Security Division reviews all
more serious incidents, not every incident receives the same level of scrutiny. This is because each
incidents step of the division’s process filters out incidents from further analysis (see exhibit A).
First, the division determines whether there were injuries or property damage. Metro
Transit categorizes incidents without reported injuries or property damage as “no
judgment required” (NJR) and generally does not investigate further. Staff then
determine whether the operator could have prevented each incident that resulted in
injuries or damage. This is not to determine fault, but rather whether the operator
could have reasonably taken any action that would have prevented the incident. 3 Staff
only categorize injuries or damage as minor, major, or severe if they find the incident
was preventable. Staff then use these categorizations to recommend operator re-
training or discipline.
EXHIBIT A: Metro Transit assesses incidents for preventability and assesses those deemed
preventable for severity.
Categorized as:
Any injuries or
NO NO JUDGMENT REQUIRED
amage reported?
YES
MINOR
3 This determination is based on a national standard set by American National Standards Institute.
EXHIBIT B: Metro Transit evaluates a fifth of incidents for both operator behavior and injury
severity.
19%
PREVENTABLE
43% NOT EVALUATED
NON- FOR SEVERITY
PREVENTABLE
Less severe Metro Transit does not assess operator behavior in incidents that did not result
incidents and in injuries or damages, which leaves out information that might help prevent
near misses future collisions or injuries. Staff at both Metro Transit and the Office of Risk
can expose Management Services stressed that whether an incident results in a serious injury or
risks not can often be due to luck rather than a difference in the operator’s actions. So not
investigating incidents that did not result in injuries or damages may risk excluding
important information about operator behavior. In practice, Safety & Security Division
staff discuss patterns from these incidents informally, but these informal
conversations are not part of the documented safety management system. Division
staff indicated that they would prefer to fully review and gather data from all
incidents, regardless of resulting injury or damage, but that they lacked the resources
to do so. The FTA is encouraging transit agencies to move from reactive systems,
highly focused on serious incidents, to more proactive safety management systems
that analyze and respond to less serious events and near misses. Metro Transit’s
leadership indicated that the department would like to move toward this broader
vision of safety.
Recommendation 1
The Metro Transit Department should identify and address risks for future
incidents by formally analyzing and using data from all safety incidents, not just
those that result in injuries or damages that the operator may have been able to
prevent.
Metro Transit While the Safety & Security Division analyzes data across incidents to find
analyzes patterns and prevent future safety incidents, it could expand this effort to
incident data increase safety. The FTA recommends the identification, assessment, and mitigation
and takes of hazards as a key part of a modern safety management system. One way Metro
steps to Transit does this is by compiling and analyzing the locations of collisions to show
reduce risks frequently troublesome intersections or roadways. With this information, Metro
Transit informs operators of potential hazards or works with the relevant jurisdiction
to remove the hazard. Metro Transit could expand and strengthen these types of
proactive efforts by incorporating more data on leading indicators, as discussed
below. The Safety & Security Division currently has six staff positions that review the
thousands of incidents that occur each year. The division stated that it would not have
capacity to conduct deeper analysis without additional staffing, especially if it were
reviewing additional incidents.
Metro Transit Metro Transit does not provide efficient access to all the safety-related data it
could improve has to the Safety & Security Division, limiting its ability to identify potential
analysis by hazards. The FTA recommends transit agencies broaden the scope of safety data
expanding collection and increase their focus on hazard identification across the organization.
data available For example, the FTA lists customer complaints about unsafe operator behavior as a
to the Safety key source of information. However, the customer complaint system at Metro Transit
& Security is not easily accessible by Safety & Security Division staff; they have direct access to
Division security-related complaints, but not safety-related complaints (see exhibit C). When
Metro Transit receives a complaint, the complaint goes to the operator’s base chief
who determines, on a case-by-case basis, whether the operator needs re-training or
counseling. Similarly, the Safety & Security Division does not have efficient access to
information about operator traffic tickets. The Safety & Security Division would have
to request the data to use it for identifying risks or trends. If the division had more
efficient access to data like safety complaints and traffic violations, it would be better
able to recognize potential hazards and recommend appropriate response measures
to prevent future incidents.
EXHIBIT C: Metro Transit does not provide efficient access to all the safety-related data it has to
the Safety & Security Division, which limits its ability to identify potential hazards.
Training data
Not shared
or not easy Complaint data
to access
Source: King County Auditor’s Office analysis
Recommendation 2
The Metro Transit Department should provide the Safety & Security Division
with efficient access to safety-related data across the organization, including
operator safety complaints and traffic offenses, so the division can use that data
to identify potential risks.
Collecting data Metro Transit does not record data on factors that cause or contribute to
on leading collisions or injuries, limiting its ability to find patterns and proactively prevent
indicators can future incidents. Metro Transit collects data from both the operator’s initial reports
help analysis and subsequent investigations, and it keeps this data in a database. Although staff
identify issues that might have caused or contributed to an incident, they do not
record it in a way that would be easy to analyze. For example, Metro Transit staff
identified operator fatigue as a potential cause of a collision, but fatigue is not a field
in the database that Safety & Security Division staff can query. This means that while
division staff can identify fatigue in individual cases, they cannot use data to show
how often fatigue is a contributing factor to collisions across the agency.
Other factors that might help Metro Transit find causal patterns include:
• how long the operator had been on their shift when the incident occurred
• how recently the operator had a rest break before the incident, and how long
the break was
• if the operator recently worked any overtime, and if so, how much
• if the operator was running behind schedule when the incident occurred.
These are just some examples of potential hazards or causal factors the Safety &
Security Division could consider tracking, but the department does not collect data in
a way that allows the division to easily analyze these factors across all incidents.
Collecting and structuring this data would allow Metro Transit to better identify
whether these are frequent hazards, design mitigation strategies to address them, and
measure the impact of those mitigation strategies.
Recommendation 3
The Metro Transit Department’s Safety & Security Division should determine and
document what additional data fields would be helpful for identifying the causes
of collisions and customer injuries.
Recommendation 4
The Metro Transit Department should collect the data identified in
Recommendation 3 and analyze it as part of its safety management system.
Annual Metro Transit does not require the annual refresher training recommended by
refresher the Transit Cooperative Research Program (TCRP). This may lead to operator
training complacency, which can increase the potential for incidents. According to the TCRP,
could reduce complacency is a hazard for experienced operators since repetitive actions can lead to
collisions a loss of focus. Several of the Metro Transit base chiefs we interviewed raised the
same concerns about complacency as a cause of collisions. Based on its research, the
TCRP suggests that transit agencies should require annual refresher training for all
Recommendation 5
The Metro Transit Department should develop and implement annual safety
refresher training on safe bus operations and require it for all operators.
Improved Metro Transit keeps data on trainings taken by operators, but this data is neither
training data complete nor reliable, reducing its usefulness for analysis and decision-making.
could help Metro Transit staff record information about training attendance for operators, but
effectiveness this data contains errors and lacks consistency in how staff enter training information.
This means Metro Transit cannot reliably use the data to understand what information
operators have been trained on and when it happened, reducing Metro Transit’s
ability to understand the effectiveness of its training. This is important as training can
be costly to implement and it is a key tool Metro Transit uses to ensure its operators
have the needed skills. Improving the reliability and consistency of its training data
will allow Metro Transit to better understand the impact and cost of its trainings, so
that it can make informed decisions about its requirements and offerings.
Recommendation 6
The Metro Transit Department should ensure its training data accurately
captures the date and content of trainings for each operator, and it should use
this data to assess the effectiveness of its trainings.
4 National Academies of Sciences, Engineering, and Medicine 2017. Successful Practices and Training Initiatives to Reduce
Accidents and Incidents at Transit Agencies. Washington, DC: The National Academies Press.
Recommendation 1
The Metro Transit Department should identify and address risks for future incidents by formally
analyzing and using data from all safety incidents, not just those that result in injuries or damages
that the operator may have been able to prevent.
Agency Response
Concurrence CONCUR
Recommendation 2
The Metro Transit Department should provide the Safety & Security Division with efficient access
to safety-related data across the organization, including operator safety complaints and traffic
offenses, so the division can use that data to identify potential risks.
Agency Response
Concurrence CONCUR
Recommendation 3
The Metro Transit Department’s Safety & Security Division should determine and document
what additional data fields would be helpful for identifying the causes of collisions and customer
injuries.
Agency Response
Concurrence CONCUR
Comment Dedicated work effort from Operational Safety SMEs and Base Ops
Management to identify required needed information will be part of the
data needs assessment conducted as part of Recommendation #2.
Recommendation 4
The Metro Transit Department should collect the data identified in Recommendation 3 and
analyze it as part of its safety management system.
Agency Response
Concurrence CONCUR
Recommendation 5
The Metro Transit Department should develop and implement annual refresher training on safe
bus operations and require it for all operators.
Agency Response
Concurrence CONCUR
Implementation date Starting in March 2023, Metro will start assigning all operators to the 8
hour Continuing Education Training with the objective that the training
will be completed by the end of 2024.
Responsible agency Metro Transit
Comment With our current Operator and First-line supervisor shortage, we do not
have the ability at this time to start these trainings. With additional
First-line Supervisors graduating in late 2023 and early 2024 (as well as
increased operator counts) Bus Operations will then be able to
aggressively start completing these trainings.
Recommendation 6
The Metro Transit Department should ensure its training data accurately captures the date and
content of trainings for each operator, and it should use this data to assess the effectiveness of its
trainings.
Agency Response
Concurrence CONCUR
incident data using Metro Transit’s data on mileage and hours of bus operations. We also conducted
qualitative analysis of descriptive information about incidents. We gathered and assessed Metro Transit’s
data on operator training.
We reviewed requirements, research, and guidance from federal agencies like the Transit Cooperative
Research Program and Federal Transit Administration as well as industry organizations like the American
Public Transportation Association. We also interviewed staff and reviewed data from relevant county
agencies such as the Office of Risk Management Services and Safety & Claims.
Recommendation 1
The Metro Transit Department should identify and address risks for future incidents by
formally analyzing and using data from all safety incidents, not just those that result in
injuries or damages that the operator may have been able to prevent.
Recommendation 2
The Metro Transit Department should provide the Safety & Security Division with efficient
access to safety-related data across the organization, including operator safety complaints
and traffic offenses, so the division can use that data to identify potential risks.
Recommendation 3
The Metro Transit Department’s Safety & Security Division should determine and document
what additional data fields would be helpful for identifying the causes of collisions and
customer injuries.
Recommendation 4
The Metro Transit Department should collect the data identified in Recommendation 3 and
analyze it as part of its safety management system.
Recommendation 5
The Metro Transit Department should develop and implement annual refresher training on
safe bus operations and require it for all operators.
Recommendation 6
The Metro Transit Department should ensure its training data accurately captures the date
and content of trainings for each operator, and it should use this data to assess the
effectiveness of its trainings.
ABOUT US The King County Auditor’s Office was created by charter in 1969 as an independent
agency within the legislative branch of county government. The office conducts
oversight of county government through independent audits, capital projects
oversight, and other studies. The results of this work are presented to the
Metropolitan King County Council and are communicated to the King County
Executive and the public. The King County Auditor’s Office performs its work in
accordance with Government Auditing Standards.